Policy Title: Joint Care Policy for Patients with Physical, Mental or Learning Disability Needs

Joint Policy for Cumbria Partnership NHS Foundation Trust & North Cumbria University Hospital NHS Trust Policy Title: Joint Care Policy for Patients with Physical, Mental or Learning Disability Needs Reference POL/CLIN/003 Version 8.0 Date Ratified 26/09/2018 Next Review Date 30/09/2021 Accountable Director Policy Author Director of Operations ALIS Clinical Lead/Clare Torn, Network Manager Please note that the Intranet / internet Policy web page version of this document is the only version that is maintained. Any printed copies or copies held on any other web page should therefore be viewed as uncontrolled and as such, may not necessarily contain the latest updates and amendments. Cumbria Partnership NHS Foundation Trust North Cumbria University Hospitals NHS Trust Page 1 of 18

Policy On A Page SUMMARY & AIM KEY REQUIREMENTS This policy outlines the roles and responsibilities for staff from both Cumbria Partnership NHS Foundation Trust and Acute Hospital Trusts in providing seamless care for service users and patients who need to access services from the respective Trusts. The policy provides guidance on transferring patients between Trusts and referral routes into mental health and learning disability services from an acute trust. TARGET AUDIENCE: Nurses, Midwives, AHPs, Matrons, OSMs GMs, FY1, FY2, Consultants, Senior Managers, Executive and Non-executive Directors TRAINING: Staff are required to read this policy. Ward Managers will ensure this is included within the staff local induction. 1. Prior to transferring of patients, CPFT will contact the acute hospital and; Discuss with allocated nurse the clinical presentation and risk factors, sharing any previous risk history Agree to fax risk assessment to acute staff if required Agree allocated time slot for ALIS staff to attend Discuss and agree risk management plan with acute staff, agreeing a plan of action should there be any problems prior to ALIS arriving 2. On admission the Acute staff will; Receive and orientate mental health / Learning Disability patients to their clinical area. Complete a comprehensive nursing and medical assessment. Develop an individualised care plan. Receive an up to date risk assessment and management plan for the service user from the referring mental health ward staff. Communicate updates and emerging concerns to relevant CPFT staff. 3. When a patient is transferred back to CPFT the acute staff will provide the following Patients on going medical needs and treatments, including medication Future outpatients appointments On-going medical treatments Supply of medication for medical problems 4. The Mental Health Escort with remain with the patient in the acute setting if the risk assessment states this is required. Page 2 of 18

TABLE OF CONTENTS 1. INTRODUCTION... 4 2. PURPOSE... 4 2.1. SCOPE... 4 2.2. STATEMENT OF INTENT... 5 3. POLICY DETAILS... 5 3.1 Acute Hospital Trust patients who require intervention of mental health/ learning disabilities services... 5 3.1.1 Acute Hospital Trust patients referred to CPFT... 5 3.2 Circumstances Leading to Transfer of Service User from a mental health/ learning disability ward from CPFT to an Acute Hospital... 5 3.3 Legal Aspects of Caring for Service Users... 6 3.4 Care of Service User Detained Under a Section of the Mental Health Act Being Transferred to the Acute Hospital... 7 3.5 Service Users Who are not Medically Fit to Receive Mental Health Services but Present Serious Risk to Self and/or Others... 7 3.6 Patient under the influence of substances in an Acute Hospital Setting... 7 3.7 Care of patients with learning disabilities within an Acute Hospital... 8 3.8 Child and Adolescent Mental Health Services Responsibilities (CAMHS)... 8 4. TRAINING AND SUPPORT... 8 5. PROCESS FOR MONITORING COMPLIANCE... 8 6. REFERENCES:... 9 7. ASSOCIATED DOCUMENTATION:... 10 8. DUTIES (ROLES & RESPONSIBILITIES):... 10 8.1 Chief Executive / Trust Board Responsibilities:... 10 8.2 Executive Director Responsibilities:... 10 8.3 Managers Responsibilities:... 10 8.4 Staff Responsibilities:... 11 8.4.1 A&E Clinical Staff... 11 8.4.2 Staff operating the Single Point of Access (SPA) to CPFT Services... 11 8.4.3 Psychiatric Liaison Services... 11 8.4.4 Acute Hospital Staff... 12 8.4.5 CPFT Clinical Staff... 12 8.4.6 Staff Working Out of Hours... 13 8.5 Mental Health Care Group Governance Board and Specialist Services Care Group Governance Board Responsibilities:... 13 9. ABBREVIATIONS / DEFINITION OF TERMS USED... 14 APPENDIX 1 FLOWCHART FOR CPFT SERVICE USERS WHO NEED ACUTE HOSPITAL CARE... 15 APPENDIX 2... 16 Page 3 of 18

1. INTRODUCTION The aim of such documents as No Health without Mental Health (Department of Health 2011) and Learning Disability improvement standards for NHS trusts (NHS Improvement 2018 is that people with mental health problems and Learning Disabilities will have good physical health and fewer people will die prematurely, and more people with physical ill health will have better mental health. The Government has stated that mental health should be treated on a par with physical health across the health and social care system. People with long-term physical conditions have higher than average rates of mental ill health. People with co-existing mental health conditions have poorer outcomes (including higher mortality rates) from a range of long-term conditions including heart disease and diabetes. (Department Of Health 2011) People with mental health / learning disability needs will from time to time require care or treatment within acute hospital settings and this policy will ensure that the mental health and learning disability needs of these patients are not compromised and that they remain safe while receiving treatment received with North Cumbria University Hospitals NHS Trust and Morecambe Bay University Hospitals NHS Trust. Whilst receiving services from Cumbria Partnership NHS Foundation Trust occasions may arise when the changed nature of the service user s physical presentation requires intervention involving acute hospital services. Patients who are in receipt of care from an Acute Hospital such as those who present to Accident and Emergency Departments or receiving in-patient care may require interventions from mental health or learning disability services. The overall aim of this policy is to ensure that all care and treatment is offered in a way which does not compromise privacy, dignity or respect, regardless of the person s age, gender, disability, sexual orientation, race, religion or faith. 2. PURPOSE This policy outlines the roles and responsibilities for staff from both Cumbria Partnership NHS Foundation Trust and Acute Hospital Trusts in providing seamless care for service users and patients who need to access services from the respective trusts. The policy provides guidance on transferring patients between trusts and referral routes into mental health and learning disability services from an acute trust. 2.1. SCOPE This policy applies to all those staff who provide care for service users: - Presenting to Accident & Emergency Departments in Acute Hospitals with symptoms of mental ill health and / or acute mental health crisis. Page 4 of 18

North Cumbria University Hospitals Trust and University Hospitals of Morecambe Bay Foundation Trust in patients who display symptoms of mental ill health. Service users being transferred between mental health and learning disability wards from Cumbria Partnership FT Trust to North Cumbria University Hospitals Trust and University Hospitals of Morecambe Bay. 2.2. STATEMENT OF INTENT Cumbria Partnership NHS Foundation Trust is committed to collaborative working ensuring the highest possible standards of healthcare for service users. This policy provides a clear framework for all staff working within Cumbria Partnership NHS Foundation Trust; North Cumbria University Hospitals Trust and University Hospitals of Morecambe Bay to access to acute physical healthcare, mental health and learning disability services. The health and wellbeing of service users regardless of the initial place of care should be the overriding concerns of all clinical staff at all times. 3. POLICY DETAILS 3.1 Acute Hospital Trust patients who require intervention of mental health/ learning disabilities services The majority of patients who are treated in an acute hospital setting will not develop mental health problems and their care plan will meet their needs accordingly. However a small minority of patients treated in an acute hospital trust setting may develop signs and symptoms of mental illness/ acute mental health crisis that may require intervention by mental health professionals (See Appendix 1). 3.1.1 Acute Hospital Trust patients referred to CPFT When patients are referred to CPFT and are awaiting assessment by psychiatric liaison, the Acute hospital will provide a safe environment for patients within the acute hospital ward or department. A risk assessment will be undertaken and any care needs addressed. If required, formal emergency detention under the Mental Health Act should be considered. Staff should follow their Trust Guidelines for the Implementation of The Mental Health Act 1983 3.2 Circumstances Leading to Transfer of Service User from a mental health/ learning disability ward from CPFT to an Acute Hospital The clinical care team at CPFT may decide independently or in consultation with Acute Hospital that the service user requires a period of care, assessment or treatment within a local acute hospital. The flowchart on appendix 2 shows the process to be followed. Page 5 of 18

An urgent / emergency assessment of the service user s physical health is required by the relevant medical staff. Admission into an acute hospital ward is required. This will follow an assessment directly from the mental health in-patient unit or within Accident and Emergency or other assessment unit or occur directly from the mental health in-patient unit. The service user is required to attend the acute hospital for a scheduled clinic appointment or for a diagnostic procedure e.g. X-ray. NB: The mental Health Escort needs to stay with the patient in the acute setting if the risk assessment and management plan states this is required. If patient is admitted a supply of current medication must be provided to the receiving ward if necessary. 3.3 Legal Aspects of Caring for Service Users Care of Informal Service User Being Transferred to the Acute Hospital (Not Detained under Mental Health Act) from a MH inpatient unit A service user will have a risk assessment undertaken by CPFT staff prior to transfer. This will be regularly reviewed in terms of their mental health issues. A member of the referring CPFT team will make contact on a daily basis. This may be by telephone. A handover of appropriate information including risk assessment will be given to the receiving Acute Hospital clinician/nurse by the referring nurse. This will be both written and verbal. If a service user requires observation from a mental health perspective whilst receiving care in Acute Hospital then a member of staff will be supplied by CPFT. This will not necessarily be a registered nurse. Medication/treatment cannot be given without consent from the service user unless the service user is subject to Part 4 of the Consent to Treatment under the Mental Health Act. This should also take into consideration the Mental Capacity Act. Being detained under the Mental Health Act does not automatically mean that the service user does not have capacity, and this should be assessed on a regular basis by the appropriate clinician. Additional guidance can be found in trust policy POL001/010 Consent to Examination or Treatment Any discussions re: transfer and subsequent communications about the service user must be documented in the service user s CPFT notes and the Acute Hospital patient records. Page 6 of 18

3.4 Care of Service User Detained Under a Section of the Mental Health Act Being Transferred to the Acute Hospital All of the above and: A detained service user requiring transfer to ACUTE HOSPITAL will be placed under section 17 leave of Mental Health Act and the appropriate documentation will be completed by the referring CPFT team. If the treatment required is of an emergency nature, the documentation will be completed retrospectively by the CPFT referring team/approved clinician. CPFT will retain the responsibility for the patient s detention and treatment under the Mental Health Act (1983) and should ensure that all legal requirements are met in the patient s day to day treatment. It is not a legal requirement for mental health staff to remain with patients who are detained under the MHA 1983, but as with informal patients a risk assessment will be undertaken to identify if this is required. 3.5 Service Users Who are not Medically Fit to Receive Mental Health Services but Present Serious Risk to Self and/or Others The CQC has published guidance for General hospitals that rarely use the mental health act to detain patients. The North Cumbria University Hospital trust policies the Management of Self Harm; and the Detention of Patients using section 5(2) of the Mental Health Act (1983), acute hospital staff will follow that guidance on the care and management of patients who need to be detained for their own safety and/ or the protection of others due to the presence of mental disorder. Local policy of University Hospitals of Morecambe Bay NHS Trust will also be used in that setting. Patients will be transferred to a mental health ward / or receive the intervention from CPFT services as soon as their physical health permits, so that they may receive the mental health care and treatment for which they have been detained. 3.6 Patient under the influence of substances in an Acute Hospital Setting Service users who are under the influence of substances within an acute setting would not be assessed by the psychiatric liaison where: Due to intoxication of substances the service user is assessed as lacking capacity. Due to the intoxication of substances there are concerns and significant physical risks about the physical health and wellbeing of the individual. Due to the intoxication the service user is unable to engage in the assessment process. In these circumstances the assessment of capacity to participate in an assessment process should be undertaken initially by the acute hospital staff and this needs to be clearly documented in the clinical notes and communicated to the psychiatric liaison team. The practitioner will need to satisfy him/herself that Page 7 of 18

the service user has/has not capacity to participate in the assessment process and will need to liaise on a regular basis with the acute hospital staff to ensure that the assessment occurs at the earliest opportunity. 3.7 Care of patients with learning disabilities within an Acute Hospital If the service user is in contact with learning disability services then it is important that the person co-ordinating their care is contacted as soon as possible. They will be a valuable source of information and support to both the acute hospital and family. Any reasonable adjustments needed should be discussed and planned as soon as possible. Ask the patient or carer if they have a Hospital Passport and check for a learning disability alert on Lorenzo as this may provide you with important information about communication, care needs etc. Consent and capacity should be assessed on an individual basis. If the person is detained under the MHA and they attend the hospital without an escort- sharing of risk assessment and S17 form. 3.8 Child and Adolescent Mental Health Services Responsibilities (CAMHS) CAMHS is a service for children, young people and families with significant, severe, complex or persistent emotional, behavioural, mental health, psychological and / or relationship difficulties. CAMHS offers a service to children and young people up to 18 years of age. Referrals should only be made for children, young people and families who are experiencing significant, severe, complex or persistent emotional, behavioural, mental health, psychological and / or relationship difficulties. Referrals are normally only considered when, despite the involvement of other professionals and agencies, specialist input is still needed. If in doubt about making a referral to the CAMHS service, telephone the local team for advice. Out of hours the psychiatric liaison service will complete a risk assessment for young people over the age of 16 if they do not require admission to the acute hospital. This is to ensure the young person is safe whilst waiting for assessment from the specialist CAMHS service. However, they are unable to provide assessment or treatment. All young people under the age of 16 should be managed by paediatric services whilst waiting for a specialist CAMHS assessment 4. TRAINING AND SUPPORT Training in the use of this policy will be delivered in accordance with the Trusts training needs analysis. Attendance at training is managed in accordance with the Trust s Learning and Development Policy 5. PROCESS FOR MONITORING COMPLIANCE Page 8 of 18

The process for monitoring compliance with the effectiveness of this policy is as follows: Aspect being monitored Service users who are admitted into an acute ward to ensure that:- Initial assessment and triage undertaken with seamless transition to an acute ward Monitoring Methodology An audit of 10 transfers per General Hospital location Reporting Presented by Committee Deputy Director of Operations Senior Management Team Clinical Governance Committee & Deputy Director of Operations Frequency Annual Acute patients receive timely access to CPFT service An audit of 10 referrals per Clinical Locality ALIS / Liaison service Deputy Director of Operations Senior Management Team Clinical Governance Committee & Deputy Director of Operations Annual Wherever the above monitoring has identified deficiencies, the following must be in place: Action plan Progress of action plan monitored by the Senior Management Team Clinical Governance Committee minutes Risks will be considered for inclusion in the appropriate risk registers 6. REFERENCES: Academy of Medical Royal Colleges; (2008); Acute Trust; A guide by practitioners for managers and commissioners in England and Wales. Department of Constitutional Affairs (2007) Mental Capacity Act 2005: Code of Practice. London, TSO Department of Health (2008) Code of Practice: Mental Health Act 1983. London,TSO Department of Health (2011) No Health Without Mental Health London TSO National Institute for Health & Clinical Excellence (2004) Self Harm Guideline. http://guidance.nice.org.uk/cg16/guidance/pdf/english NHS Improvement (2018) The learning disability improvement standards for NHS trusts NICE Guidance Page 9 of 18

Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services (CG136) Transition between inpatient mental health settings and community or care home settings (NG53) Learning Disabilities and behaviour that challenges: service design and delivery (NG93) 7. ASSOCIATED DOCUMENTATION: https://cdn.cumbriapartnership.nhs.uk/uploads/policydocuments/physical_examination_and_care_of_service_user_pol_001_012. pdf. https://cdn.cumbriapartnership.nhs.uk/uploads/policydocuments/care_coordination_policy_pol-001-001.pdf https://cdn.cumbriapartnership.nhs.uk/uploads/policy- documents/mental_health_act_guidelines_on_section17_leave_pol-001-005-006.pdf 8. DUTIES (ROLES & RESPONSIBILITIES): 8.1 Chief Executive / Trust Board Responsibilities: The Chief Executive and Trust Board jointly have overall responsibility for the strategic and operational management of the Trust, including ensuring that Trust policies comply with all legal, statutory and good practice requirements. 8.2 Executive Director Responsibilities: All policies have a designated Executive Director and it is their responsibility to be involved in the development and sign off of the policies, this should ensure that Trust policies meet statutory legislation and guidance where appropriate. They must ensure the policies are kept up to date by the relevant author and approved at the appropriate committee. 8.3 Managers Responsibilities: Line managers must ensure that all staff involved in the care and management of patients with mental health and or learning disabilities read this policy. Page 10 of 18

Line managers have a responsibility to monitor compliance of their staff in adherence to this policy and support the auditing of practice. Where deficiencies are found they have a responsibility for implementing action points arising. 8.4 Staff Responsibilities: 8.4.1 A&E Clinical Staff At triage and examination a physical and mental health assessment will be undertaken either by the nursing staff or medical staff depending upon the presenting symptoms of the patient. The referral route to mental health services, if required, will be via the flow diagrams on Appendices 1 & 2. 8.4.2 Staff operating the Single Point of Access (SPA) to CPFT Services Access to mental health services occurs via the Single Point of Access (SPA) (0300 123 9015) and these are available across all trust localities. Referrals to older adult liaison teams are direct to the team through the relevant older adult community team or out of hours through the SPA telephone number Access to inpatient beds in CPFT occurs via the Access and liaison teams (ALIS) for mental health wards and the Learning Disability Consultant and Community Teams for learning disability units. Acute hospital clinical staff will need to contact the SPA in the first instance to make a referral and this will be facilitated by an appropriately trained person who will then contact the practitioner. 8.4.3 Psychiatric Liaison Services Liaison practitioners will: Assess service users in medical settings when they are medically able to participate within the assessment process. Prioritise assessments based on clinical presentation and risk and the service user will be seen within an agreed timescale Communicate all clinical assessments including risk assessment and management plans with staff in Acute Hospital Trusts and these will be documented within the Acute trusts and the CPFT s clinical records. Provide ongoing assessment, support and brief intervention for those with acute psychiatric mental health needs within the general hospital setting. Advise on signposting service users to more appropriate mental health and social needs services as required. Page 11 of 18

8.4.4 Acute Hospital Staff On receiving CPFT service users from mental health or learning disability wards who require acute hospital in-patient care, staff will: Receive and orientate mental health / Learning Disability patients to their clinical area. Complete a comprehensive nursing and medical assessment. Read Hospital Passport and ensure this is visible to other clinicians Develop an individualised care plan. Receive an up to date risk assessment and management plan for the service user from the referring mental health ward staff. Communicate updates and emerging concerns to relevant CPFT staff. Contact ALIS regarding transfer of patients back to CPFT and that this will involve the patient being transferred to an available bed not necessarily within their locality. Provide handover to CPFT staff of:- o Patients on going medical needs o Future outpatients appointments o Ongoing medical treatments o Supply medication for medical problems 8.4.5 CPFT Clinical Staff When an acute medical intervention is required CPFT clinical staff will:- Undertake initial assessment and document in the case notes identifying the presenting problem and identified needs. Contact appropriate senior staff within the acute trust to discuss case and arrange admission if required senior staff member contacts the acute hospital site co-ordinator to arrange a bed in acute hospital West Cumberland Hospital via bleep 5648 or mobile 07789-770349 Cumberland Infirmary 01228 8523444 bleep number 185, site co-ordinator 0782 689 4891 Westmorland General Hospital 01539 732288 and bleep bed manager Furness General Hospital 01229 870870 and bleep bed manager Ward nursing staff to transfer service user to the identified ward in acute hospital and will provide a verbal handover & supply the ward with the following : o Risk assessment, o Relevant care plan and Hospital Passport o Supply of medication, o Maintain daily contact with the ward either on face to face or verbal, o Telephone basis depending upon the health needs of the service user. o If risk assessment identifies heightened risk then CPFT staff will discuss with Acute staff re the management plan. This may be ward manager to ward manager and include all care teams. o CPFT staff will provide MH escort if identified on risk assessment as required. Page 12 of 18

8.4.6 Staff Working Out of Hours All clinical localities in CPFT have urgent medical care contracts in place with Cumbria Health on Call (CHOC) who provide out of hours medical provision for urgent physical health care and should be contacted in the first instance for all urgent physical health concerns that occur out of hours. If the service user needs to be transferred to an acute medical setting out of hours this will need to be initiated by CHOC in consultation with the site co-ordinator. For all Emergency calls the Ambulance Service will be contacted to attend the service user. 8.5 Mental Health Care Group Governance Board and Specialist Services Care Group Governance Board Responsibilities: The Chair of the approving boards will ensure the policy approval is documented in the final section of the Checklist for Policy Changes. The committee will agree the approval of the final draft of the policy. Page 13 of 18

9. ABBREVIATIONS / DEFINITION OF TERMS USED ABBREVIATION ALIS CHAMS CHOC CPFT CQC SPA DEFINITION Access and liaison teams Child and Adolescent Mental Health Services Cumbria Health On-Call Cumbria Partnership Foundation Trust Care Quality Commission Single Point of Access TERM USED Common Mental Health Problems Medical illness Mental Health Act Assessment Physically Fit: Mental Health Assessment Risk assessment DEFINITION Anxiety and depression related disorders of mild to moderate severity A physical illness is present. An assessment by a mental health practitioner to determine whether the patient has a mental disorder and if they do, what treatment and care they need. No longer requiring input from general hospital ward and not presenting any physical healthcare needs beyond the expertise of a psychiatric or learning disability ward Mental Health Assessment: An assessment by a mental health practitioner to determine whether the patient has a mental disorder and if they do, what treatment and care they need. Effective care includes an awareness of a person s overall needs as well as an awareness of the degree of risk that they may present to themselves or others. Page 14 of 18

APPENDIX 1 FLOWCHART FOR CPFT SERVICE USERS WHO NEED ACUTE HOSPITAL CARE CPFT Inpatient Requires assessment and treatment at acute hospital Emergency Urgent Routine Dial 999 Escort Required Appointment arranged Escort Required Verbal communication will be given to the ACUTE HOSPITAL emergency team on arrival at Accident and Emergency by accompanying CPFT staff. Copy of recent risk assessment will be provided by CPFT escort CPFT Nurse in Charge is responsible for ensuring that the receiving Acute hospital team have all clinical information required CPFT arranges transport and escort notes and medication accompany patient escort Page 15 of 18

APPENDIX 2 Page 16 of 18

DOCUMENT CONTROL Equality Impact Assessment Date November 2018 Sub-Committee & Approval Date Specialist Services Care Group Governance Board 11/09/2018 Mental Health Care Group Governance Board 26/09/2018 History of previous published versions of this document: Trust Version Ratified Date Review Date CPFT - POL/001/032 NCUH CG09 CPFT - POL/001/032 NCHE/MH/ACUT E/01 (NCUHT) POL/001/005/00 8 (CPFT) Date Published 7.0 11/05/16 12/06/18 12/06/16 6.0 24/09/2012 31/09/2014 5.0 4.0 3.0 2.0 August 2009 1.0 September 2011 August 2009 Disposal Date Statement of changes made from previous version 7.0 Version Date Section & Description of change 7.1 20/09/19 Inclusion of reference to Learning Disability Document in Introduction 7.2 20/09/19 Addition of reference to use of Hospital Passport and need for consideration of Reasonable adjustments for people with a learning disability 7.3 20/09/19 Statement added re people under MHA and attend Acute Hospital without escort should have a risk assessment and S17 Form 7.4 20/09/19 Moved Appendix 1 and 2 from the start of the document to the end 7.5 20/09/19 Moved to new agreed shared template Abbreviations added Hyperlinks to appendices added Stakeholder listing updated Page 17 of 18

List of Stakeholders who have reviewed the document Name Job Title Date Clare Torn Network Manager, Mental Health 08/08/2018 Services, CPFT Dave Eldon Head of Mental Health Legislation Unit 08/08/2018 & Legal Services Linda Turner Q&S Lead Specialist Services, CPFT 17/08/2018 Nicola Hanlon Clinical Lead ALIS/Home Treatment, 17/08/2018 CPFT Loraine Tottman Safeguarding Advisor and Learning 20/09/2018 Disability Lead, NCUH Brian Evans Clinical Nurse Specialist for Learning 20/09/2018 Disabilities, UHMB Amanda Barwick Crisis Resolution & Home Treatment - 21/09/2018 East Lesley Paterson Associate Director Nursing, Specialist 21/09/2018 Services Care Group Chief Matrons, NCUH 21/09/2018 Matrons for Emergency Department, 21/09/2018 Surgical and Medicine Care Groups NCUH Ward Managers, Children and Young Peoples Wards, NCUH 21/09/2018 Page 18 of 18